On November 22, 1998, now-paralyzed
actor Christopher Reeve starred in ABC’s made for TV movie, Rear Window,
and his astonishing comeback recently led to nominations for Golden Globe
and Screen Actor’s Guild awards. He has also been an activist for funding
for spinal cord research and insurance reform, and on the same day his
TV movie aired, Parade magazine published an interview between Reeve
and James Brady in which Reeve advocated controversial federal legislation
to raise health insurance caps from $1 million to $10 million.

Republican Senator James
Jeffords of Vermont had proposed such a provision in an amendment to the
Health Insurance Portability and Accountability Act of 1996. The amendment
would have barred the imposition of a lifetime limit of less than $10 million
for a group health plan serving more than 25 people. In April 1996, Congress
voted to table the Jeffords Amendment, but, Reeve continues to work with
Senator Jeffords and others to raise the insurance cap. The Republican
Policy Committee summarized discussions surrounding the bill. These discussions
noted that the current $1 million cap is not a legal requirement, but an
industry standard that was developed 20 years ago and affects 70% of Americans.
It is believed that $10 million today is the equivalent of $1 million twenty
years ago. All agreed that the law would raise insurance premiums, and
some feared that small employers might provide no insurance rather than
high cost insurance.

A $10 million cap inherently
suggests it is appropriate to spend $10 million on the health of one person.
The science fiction television program The Six Million Dollar Man,
which premiered in 1974, featured an injured astronaut who received superior
artificial limbs and superior vision at a cost of $6 million. My neighbor
at that time commented that no one would ever spend that much money on
one person. His assessment recognized that all reimbursement programs,
whether funded by government, private insurance, or private HMO, have limited
money.

Some states will not spend
exorbitant amounts for special procedures. James Childress, in his book
Practical
Reasoning in Bioethics (1997), quotes the governor of Oregon as to
why Oregon limits Medicaid funding on transplants to cornea and kidney
transplants: "How can we spend every nickel in support of a few people
when thousands never see a doctor or eat a decent meal?" However, data
show that millions are spent on single individuals. The Medicaid program
often spends amounts exceeding $1 million.

The discussions surrounding
the Jeffords Amendment noted that the average lifetime cost of a spinal
cord or severe head trauma injury is $5 million. Price Waterhouse estimated
that the increased cap would save Medicaid $7 billion over the next 7 years
by shifting costs to private insurers. It is estimated that 230,000 individuals
are in a position similar to that of Christopher Reeve.

A legislatively mandated
$10 million cap is not the solution. The amendment in this case would apply
to employers with as few as 26 employees. Where expenses are high and an
insurance company spreads the costs among subscribers, the employer may
find premiums out of reach. On February 21, 1999, the Houston Chronicle
cited a report by professors at Baylor University which quantified an increase
in uninsured citizens at 0.2 to 0.6 percent for each one percent increase
in insurance premiums. While employment-based health insurance has been
the standard in the United States, it is not always the best answer. The
bare shift of high liability to employers and insurance companies would
not guarantee that necessary care is provided.

Finally, the amendment could
have unanticipated consequences based on other laws that mandate certain
types of care. For example, the Mental Health Parity Act requires certain
employers to apply similar caps to physical and mental disabilities. Also,
insurance companies must accept certain people regardless of their health.
For example, an employee with a disabled son who changes jobs is entitled
to insurance with the new employer without regard to expensive treatment
needed for his son. This adds an element of adverse selection to new policies;
currently that risk is capped at $1 million or less.

While a mandate on insurance
companies is not the answer, government action could be helpful. Many states
have funds to assist victim of crimes. The funds are often created by court
assessments. A similar fund could be created using assessments against
activities that cause the most injuries: increased drivers’ licensing and
registration fees; a gas tax; gun tax; ammunition tax; alcohol tax; tax
on dangerous sporting events; and a surcharge for drunk driving violations.
The program could establish fault-based criteria for distribution so that
reckless conduct is not subsidized and to allocate limited funds. This
would strike a reasonable balance by providing essential care and services
to as many critically injured people as possible without drastically increasing
health insurance costs and the number of uninsured.